The Hindu Business Line : Making abortions safe

According to a study (2002-2004), `Unwanted Pregnancy and Post-abortion Complications in Pakistan,' conducted by the Population Council of Pakistan, the estimated national abortion rate is 29 per 1,000 women in the reproductive age-group. This rate is higher than neighbouring India and almost similar to Bangladesh.

However, if this rate persists, every Pakistani woman would have experienced at least one abortion in her lifetime, says the study. The study — supported by the Packard Foundation, World Health Organisation, Alan Guttmacher Institute, Department for International Development and UNFPA — clearly points to the high level of unwanted pregnancies, induced abortions and post-abortion complications in the country.

The study was conducted in both urban and rural areas. As abortion is illegal, safe abortion services are rarely available to women, who are forced to visit illegal clinics run by traditional birth attendants (TBAs) or midwives, says the study. According to Dr Sadiqua N. Jafarey, President, National Committee for Maternal Health (NCMH) and Professor of Obstetrics and Gynaecology at the Ziauddin Medical University, TBAs — trained or otherwise — don't have the requisite skills or the infrastructure to perform safe abortions.

Besides being cheaper, women approach dais (midwives) because they "feel their secret will be kept", says Dr Jafarey. According to the study, 23 per cent of the women who resort to unsafe abortions by unskilled health providers (since most reputed doctors and hospitals will not offer abortion facilities) are later hospitalised for complications.

Complications from septic abortions are a leading cause of maternal deaths. The findings also point to the vast unmet need for family planning services. Most abortions are carried out to prevent unwanted births.

Inaccessibility of family planning services, financial constraints, and in some cases, husbands who want more children while the spouse don't are some reasons why women don't use contraception.

"One major obstacle is the fear of side effects: Many Pakistani women and men consider use of contraceptives more threatening to their health than an occasional induced abortion," the study says. "They want to space and limit the family size, and have not used any contraception," says Dr Shershah Syed, a gynaecologist at the government-owned Civil Hospital in Karachi, and also general secretary of the Pakistan Medical Association. Dr Syed meets scores of low-income women who suffer from post-abortion complications that include uncontrolled bleeding, infections, perforation of the uterus (womb), and injury to the bowel.

There have been cases where intestines — mistaken for foetus parts — have been pulled out. The more permanent damages include infertility. It therefore becomes imperative for the government to provide improved access and quality of family planning services.

"Couples need clear, concise, complete information and counselling from trained providers," says Dr Rehana Ahmed, an international health consultant serving on the board of Greenstar Social Marketing Pakistan. A study, `Gender Perspectives on Induced Abortion: Knowledge and Attitude', conducted in two low socio-economic settlements of Karachi, found that while most people considered abortion a major sin, it was the preferred choice for a married couple.

While many men maintain that use of family planning methods is against their religion, they have no qualms about getting a pregnancy terminated. According to most doctors, "it is always with their (husband's) permission, although they will admit that religion does not allow abortion." But what is worrisome is the lack of awareness on post-abortion complications.

Among the recommendations emerging from the Population Council study, "Men should be more effectively incorporated in resolving the various problems surrounding unwanted pregnancy — ineffective contraception, induced abortion and its repercussions."

According to Dr Mohsina Bilgrami, Managing Director, Marie Stopes Society, "We need to find out why the unmet need is not being fulfilled." She said, "If factors such as poverty, illiteracy, access, communication, fear of side effects, strong hold of other stakeholders (mothers-in-law, religious and community pressures) are tackled so that women become the decision-makers, then the other factors will also be overcome."

"I think the laws should be liberalised (relaxed). Simultaneously, we need to create awareness amongst the people who matter, about the gravity of the situation and the adverse consequences of unsafe abortion," says Dr Jafarey.

Dr Syed feels abortion should be legalised to save women from complications caused by unsafe abortion. But Dr Ahmed and Dr Bilgrami think differently. They feel laws need to be relaxed but not changed, "so that abortion is made safe for those who really need it". Dr Bilgrami comments, "As in cases where it is absolutely necessary — rape, incest, danger to the life of mother and baby." Dr Ahmed relates her experience in Cambodia where she did a consultancy recently.

"Abortion is legal there since 1998, but the problem of unsafe abortions remains, as women continue to distrust the poor quality of contraceptive services. When unintended pregnancy occurs, they go for unsafe abortion." In her view, making abortion legal does not make it safe. "It seems to me that the solution lies in improving the quality of family planning services: counselling as well as increasing contraceptive choices, and at the same time informing men and women about the dangers of unsafe abortions."

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